Elbow fractures explained in a simplified, manner.

1. ELBOW AND FOREARM
FRACTURES FRACTURES
PRESENTED BY
MWADZIWANA LOUIS LAW

2. Elbow joint Anatomy

3. Fractures of the distal humerus
In adults they are associated with high-energy
injuries.
In children - falls with an outstretched arm
The AO-ASIF Group have defined three types of
distal humeral fracture:
Type A – an extra-articular supracondylar
fracture;
Type B – an intra-articular unicondylar fracture
(one condyle sheared off);
Type C – bicondylar fractures with varying
degrees of comminution.

4. Supracondylar fractures type A
rare in adults.
Usually they are displaced and unstable
In high-energy injuries there may be
comminution of the distal humerus

6. Treatment
 Open reduction and internal fixation.
 Mostly plates and screws are used
 Closed reduction is unlikely to be stable
 K-wire fixation is not strong enough to permit early
mobilization.

7. Types B and C intra articular fractures
high-energy FRACTURES AND JOINT INJURIES
injuries with soft-tissue damage.
A severe blow on the point of the elbow drives
the olecranon process upwards, splitting the
condyles apart. Swelling is considerable.
 The patient should be checked for
i. Pulselessness
ii. Pallor
iii. Pain
iv.Paresthesia
v. Paralysis

8. X-ray
 T- or Y shaped break, or else there may be (comminution).

9. Treatment type Undisplaced fractures
Joint damage- prolonged immobilization will
certainly result in a stiff elbow.
Early movement is a prime objective.
Treated by applying a posterior slab with the
elbow flexed almost 90 degrees;
movements are commenced after 2 weeks.

11. Reduction of a supracondylar fracture

12. Txt Displaced type B and C
 ORIF
 K wire can be used
 unicondylar fracture without comminution can then be
fixed with screws; if the fragment is large, a contoured
plate is added to prevent re-displacement.
 Plates with locking screws
 Postoperatively the elbow is held at 90 degrees with the
arm supported in a sling. Movement is encouraged but
should never be forced.
 Fracture healing usually occurs by 12 weeks.
 patient often does not regain full extension

14. Alternative treatments
 Elbow replacement
 The ‘bag of bones’ technique.
 The arm is held in a collar and cuff or, better, a
hinged brace, with the elbow flexed above a right
angle; active movements are encouraged as soon as
the patient is willing. The fracture usually unites within
6–8 weeks, but exercises are continued far longer. A
useful range of movement (45–90 degrees) is often
obtained.
 Skeletal traction
the patient remains in bed with the humerus held
vertical, and elbow movements are encouraged.

15. Complications of supracondylar fractures
 Vascular injury
 Nerve injury median nerve
 Volkmann’s ischemic contracture
 Malunion leading to gunstock deformity
 Myositis ossificans
 Stiffness

18. FRACTURED CAPITULUM
 rare articular fracture
 Mainly occurs in adults
 elbow is tender and flexion is grossly restricted
 Mechanism of injury
The patient falls on the hand, usually with the elbow
straight.
The anterior part of the capitulum is sheared off and
displaced proximally

19. X-rays
Bryan and Morrey classify these as:
i. Type I Complete fracture
ii. Type II Cartilaginous shell
iii. Type III Comminuted fracture.

20. Can You See The Capitulum

21. Treatment
 Undisplaced fractures can be treated by simple
splintage for 2 weeks.
 Displaced fractures should be reduced and held.
 Closed reduction is feasible, but prolonged
immobilization may result in a stiff elbow.
 ORIF is therefore preferred.
 Using headless bone screws
 Movements are commenced as soon as discomfort
permits

22. Fractured head of the Radius
Common in adults
A fall on the outstretched hand with the elbow
extended and the forearm pronated
Impaction of the radial head against the capitulum
causes the radial head to split or brake
Clinical features - tenderness on pressure over the
radial head and pain on pronation and supination

23. X-rays
 Three types of fracture are identified and classified by Mason as:
i. Type I An undisplaced vertical split in the radial head
ii. Type II A displaced single fragment of the head
iii. Type III The head broken into several fragments (comminuted).

24. Treatment
 An undisplaced split (Type I)
 Aspirating the haematoma and injecting local anaesthetic.
 The arm is held in a collar and cuff for 3 weeks; active
flexion, extension and rotation are encouraged.
 The prognosis for this injury is very good
 A single large fragment (Type II)
 reduced and held with one or two small headless screws.

25. Treatment
 A comminuted fracture (Type III).
 Always assess for an associated soft tissue injury:
i. Rupture of the medial collateral ligament
ii. Rupture of the interosseous membrane
iii. Combined fractures of the radial head and coronoid process plus
dislocation of the elbow ‘the terrible triad’.
 If any of these is present, excision of the radial head is contra-
indicated; this may lead to intractable instability of the elbow or
forearm.
 The head must be reconstructed with small headless screws or
replaced with a metal spacer.
 A medial collateral rupture, if unstable after replacing or fixing the
radial head, should be repaired.

26. Complications
 Joint stiffness both the elbow and the radioulnar joints.
 Delayed union
 Stiffness
 Myositis ossificans
 Recurrent instability of the elbow joint

27. Fractures of the olecranon
 Two broad types of injury are seen:
i. Comminuted fracture which is due to a direct blow or a
fall on the elbow
ii. A transverse break, due to traction when the patient falls
onto the hand while the triceps muscle is contracted.
 These two types can be further sub-classified into
i. Displaced fractures
ii. Undisplaced fractures.
 Subluxation or dislocation of the ulno-humeral joint in
severe injuries
 The fracture always enters the elbow joint and therefore
damages the articular cartilage.

29. Clinical features
 A graze or bruise over the elbow suggests a
comminuted fracture; the triceps is intact and the
elbow can be extended against gravity.
 With a transverse fracture there may be a palpable
gap and the patient is unable to extend the elbow
against resistance.

30. Treatment
 A comminuted fracture with the triceps intact should be
rested in a sling for a week; then encouraged to start
active movements.
 An undisplaced transverse fracture that does not
separate when the elbow is in flexion can be treated
closed.
 The elbow is immobilized by a cast in about 60 degrees
of flexion for 2–3 weeks and then exercises are begun.
 Displaced transverse fracture ORIF is done. The fracture
is reduced and held by tension band wiring.
 Oblique fractures may need a lag screw, neutralized by
a tension band system or plate.

31. Treatment
 Displaced comminuted fractures need a plate and often bone
graft.
 Following operation, early mobilization should be encouraged.

32. Main Complications
Stiffness
Non-union due to inadequate reduction and
fixation.
Ulnar nerve symptoms can develop.
Osteoarthritis

33. Radius and Ulnar bones

34. Fractures of the radius and the ulna
Common both in children and adults
Mechanism of injury
Twisting forces produces a spiral fracture with the
bones broken at different levels.
An angulating force causes a transverse fracture
of both bones at the same level.
A direct blow causes a transverse fracture of just
one bone, usually the ulna.
Additional rotation deformity may be produced
by the pull of muscles attached to the radius

35. Clinical features
Obvious fractures due to deformity
Check for the five P’s
i. Pulselessness
ii. Pallor
iii. Pain
iv.Paresthesia
v. Paralysis

36. X-ray
Both bones are broken
In children, the fracture is often incomplete
(greenstick) and only angulated.
In adults, displacement may occur in any
direction – shift, overlap, tilt or twist.
In low-energy injuries, the fracture tends to be
transverse or oblique; in high-energy injuries it is
comminuted or segmental

37. X-ray images of the forearm

38. Treatment in children
Closed treatment because the tough
periosteum tends to guide and then control the
reduction.
The fragments are held in a full-length cast, from
axilla to metacarpal shafts (to control rotation).
For 6-8weeks.
The cast is applied with the elbow at 90
degrees.
If the fracture is proximal to pronator teres, the
forearm is supinated; if it is distal to pronator
teres, then the forearm is held in neutral.

39. Treatment in children continued
If the conservative method fails ORIF is done
Fixation with intramedullary rods is
preferred, avoid injury to the growth plates.
Alternatively, a plate or K-wire fixation can be
used.
Childhood fractures usually remodel well, but
not if there is any rotational deformity or an
angular deformity

40. Treatment in adults
 Open reduction and internal fixation
The fragments are held by inter fragmentary
compression with plates and screws.
Bone grafting is advisable if there is
comminution.
The deep fascia is left open to prevent
compartment syndrome, only the skin is sutured.
External fixation if it is a compound fracture

41. Plate and screws

42. Adult treatment
After the operation the arm is kept elevated
until the swelling subsides, and during this period
active exercises of the hand are encouraged.
If the fracture is stable
Early ROM exercises are commenced but lifting
and sports are avoided.
It takes 8–12 weeks for the bones to unite.
With comminuted fractures or unreliable
patients, immobilization in plaster is safer.

43. Complications
Early complications
Nerve injuries
Vascular injury
Compartment syndrome
Late complications
Delayed union and nonunion
Malunion and cross union
Complications of plate removal

44. Isolated fracture of the forearm
Uncommon
Caused by direct trauma
E.g. when protecting the face
Clinical features
X-ray showing fractures, ulnar fracture difficult
to see
Swelling
Deformity
Dislocations on the distal and proximal joints

45. Treatment
Isolated fracture of the ulna
Undisplaced fracture
Elbow flexed full arm cast or forearm brace.
8 weeks before full activity can be resumed.
Displaced fractures
ORIF to prevent rotational elements
Advantage allow earlier activity and avoids
the risk of displacement or non-union.

46. Treatment
Isolated fracture of the radius
Radius fractures are prone to rotary
displacement;
To achieve reduction in children the forearm
needs to be
i. supinated for upper third fractures,
ii. neutral for middle third fractures
iii. pronated for lower third fractures.
If the reduction fails; then internal fixation with a
compression plate and screws in adults, and
preferably intramedullary rods in children.

47. Isolated fractures of the forearm

48. Monteggia Fracture
Fracture of the shaft of the ulna associated with
dislocation of the proximal radio-ulnar joint and
the radiocapitellar joint.
In children, the ulnar injury may be an
incomplete fracture (greenstick or plastic
deformation of the shaft)

49. Mechanism of injury
Usually the cause is a fall on the hand; if at the
moment of impact the body is twisting, its
momentum may forcibly pronate the forearm.
The radial head usually dislocates forwards and
the upper third of the ulna fractures and bows
forwards.
Sometimes the causal force is hyperextension

50. Clinical features
ulnar deformity is usually obvious
the dislocated head of radius is masked by
swelling. A useful clue is pain and tenderness on
the lateral side of the elbow.
 The wrist and hand should be examined for
signs of injury to the radial nerve.

51. X-RAYS
The head of the radius is dislocated forwards,
and there is a fracture of the upper third of the
ulna with forward bowing.
Backward or lateral bowing of the ulna is likely
to be associated with, respectively,
Posterior or lateral displacement of the radial
head.
Trans-olecranon fractures, also, are often
associated with radial head dislocation.

52. Monteggia Fracture X-ray

53. Treatment
 Aim is to restore the length of the fractured ulna
 The ulnar fracture must be accurately reduced, with the
bone restored to full length, and then fixed with a plate
and screws.
 The radial head usually reduces once the ulna has been
fixed.
 Stability must be tested through a full ROM.
 If the elbow is completely stable, then flexion–extension
and rotation can be started after surgery.
 If there is doubt, then the arm should be immobilized in
plaster with the elbow flexed for 6 weeks

54. TREATED MONTEGGIA FRACTURE

55. Ulnar Fracture
Hume fracture - a fracture of the
olecranon with an associated
anterior dislocation of the radial
head

56. GALEAZZI FRACTURE-DISLOCATION
OF THE RADIUS
Fractured radius with dislocation of the distal
radioulnar joint
More common than the Monteggia fracture
Mechanism of injury
Fall on an outstretched hand; probably with a
rotation force.
The radius fractures in its lower third and the
inferior radio-ulnar joint subluxates or
dislocates.

57. Clinical features
Prominence or tenderness over the lower end of the
ulna.
It may be possible to demonstrate the instability of
the radio-ulnar joint by rotating the wrist.
Test for an ulnar nerve lesion
X-ray
A transverse or short oblique fracture is seen in
the lower third of the radius, with angulation or
overlap.
The distal radio-ulnar joint is subluxated or
dislocated.

58. Treatment
restore the length of the fractured bone
Conservative method is usually successful in
children
In adults ORIF and compression screws of the
radius
X-ray to verify that the distal radio-ulnar joint is
reduced

59. Reduced Galeazzi Fracture

60. Complications
Malunion because the distal fragment has no
longitudinal support
Cross union
Compartment syndrome

61. Radius fracture
Essex-Lopresti fracture - a fracture of the
radial head with concomitant dislocation
of the distal radio-ulnar joint with disruption
of the interosseous membrane.

62. Physiotherapy treatment
 The physiotherapist carries out an assessment of the
patient and then formulates a plan of treatment.
Aims of physiotherapy treatment
 To reduce any swelling.
 To regain full range of joint movement.
 To regain full muscle power.
 To re-educate full function.
 Maintain Soft Tissue and Joint Mobility
 Maintain Integrity and Function of Related Areas

63. Physiotherapy management
 soft tissue massage
 joint mobilization
 electrotherapy (e.g. ultrasound)
 taping or bracing
 ice or heat treatment
 the use of a protective gear like splints
 exercises to improve strength, flexibility and balance
 hydrotherapy
 Patient education
 activity modification eg ADL’s
 a graduated return to activity plan

64. Physiotherapy treatment
Reduce Effects of Inflammation or
Synovial Effusion and Protect the Area
Immobilization in a sling provides rest to
the part, weigh with complete
immobilization
Frequent periods of controlled movement
within a pain-free range should be
performed.

65. Salter Harris Classification

66. References
 Apley’s System of Orthopedics and Fractures